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Why wasn’t Lucy Letby stopped sooner? This is the burning question that the families of her victims, and the public, are now asking. Steve Barclay, the Health Secretary, has decided that the best means of answering it is a ‘non-statutory public inquiry’. But what is such an inquiry, and will it be better than a full-blown statutory public inquiry?
Non-statutory inquiries can be set up by anyone, at any time, to investigate anything. They proceed in private and have no legal powers to demand the disclosure of documents or to call witnesses to give evidence. But they have the twin merits of speed and informality. The former may be very valuable, particularly where urgent changes are needed. The latter can facilitate a greater degree of candour about errors that have been made, as witnesses feel less pressure than they do in the full glare of public scrutiny. But such inquiries are entirely reliant on organisations and individuals to assist them. This cannot be guaranteed, particularly where livelihoods, reputations, and even freedoms, are at stake. So they may fail where this doesn’t happen.
Non-statutory inquiries also don’t always give victims, their families, and the public, the assurances they need that the Government understands the gravity of what has happened. An example of this is non-statutory inquiry into the horrific abuse perpetrated by David Fuller – who sexually assaulted many dead bodies that were supposedly safe in a hospital mortuary. Ordered by the then Health Secretary, Sajid Javid, on 8th November 2021, its proceedings have been entirely behind closed doors and it has yet to report almost two years on.
The advent of the Human Rights Act 1998, and the incorporation into domestic law of the Article 2 right to life, has transformed coronial investigations and inquests over the last two decades. Lord Bingham’s magisterial creation of the ‘enhanced’ investigation and conclusion in R (Middleton) v West Somerset Coroner [2004] UKHL 10, [2004] 2 AC 182 (later adopted by Parliament) gave coroners greater responsibility to hold the state to account for deaths. That, in turn, has significantly improved the ways in which all inquests are conducted, not just those where Article 2 is found to be engaged. Inquests are no longer haphazard affairs. They are (ordinarily) carefully planned and structured processes; and their participants, the ‘interested persons’, are far more involved in assisting coroners with the task of identifying the proper scope of their investigations and the lawful ambit of their conclusions.
Article 2, then, has already conquered and occupied the terrain of the coroners’ courts and it is only at the frontiers of its application that legal skirmishes still occur. One such fight is the case of R (Maguire) v HM Senior Coroner for Blackpool & Fylde and another [2023] UKSC 20, which was argued before the Supreme Court on 22nd and 23rd November 2022, and in which judgment was given on 21st June 2023.
The central issue in the case was whether Article 2 required an enhanced inquest into the death of highly vulnerable woman, Jackie Maguire, who had become seriously unwell while in a private residential care home and had later died in hospital. The Supreme Court held unanimously that it did not. More importantly, in doing so, it took the opportunity to provide a detailed and authoritative account of how Article 2 applies to coronial investigations and inquests.
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